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Physician Practice Behavior and Practice Guidelines: Using Unannounced Standardized Patients to Gather Data

Journal of General Internal Medicine volume 24, pages 53–56 (2009)Cite this article

Abstract

Background

Measuring actual practice behaviors of physicians, particularly as they relate to established clinical guidelines, is challenging. Standardized patients provide one method of collecting such data.

Objective

To demonstrate the use of unannounced standardized patients in gathering data that may address adherence to guidelines in an office setting.

Design

Unannounced standardized patients (SPs) simulating an initial type 2 diabetic visit presented to community offices of 32 internists as “real” patients to record physicians’ evaluation and management.

Participants

Unannounced SPs presented to the office of 32 internists as “real” patients.

Measurements

Unannounced SPs, simulating type 2 diabetics, completed a standardized assessment sheet, based on ADA guidelines to record physicians’ evaluation and management following an initial visit. Patient charts were also reviewed to determine if evaluation adhered to the guidelines.

Results

Unannounced SPs recorded 56 visits with 32 community internists; all SPs remained undetected. All physicians asked SPs about medications. At least 50% of physicians asked about home blood sugar monitoring, last eye exam, smoking, edema, and told patients to stop smoking. Less than 50% of physicians asked about parasthesias, performed fundoscopy, examined feet, referred the patient to a diabetic educator or ophthalmologist, or gave patients suggestions regarding glucose monitoring or exercise. HbA1c was ordered in 78%, metabolic profiles in 86%, and urinalysis/microalbumin in 41% of patients.

Conclusions

Unannounced standardized patients can successfully collect important data regarding physician practices in community settings. This method may be helpful in assessing physician adherence to established clinical practice guidelines.

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References

  1. Colliver JA, Swartz MH. Assessing clinical performance with standardized patients. JAMA. 1997;278:790–4.

    PubMed  Article  CAS  Google Scholar 

  2. Adamo G. Simulated and standardized patients in OSCEs: achievements and challenges 1992–1993. Med Teach. 2003;25:262–70.

    PubMed  Article  Google Scholar 

  3. Nagoshi M, Williams S, Kasuya R, Sakai D, Masaki K, Blanchette PL. Using standardized patients to assess the geriatrics medicine skills of medical students, internal medicine residents, and geriatrics medicine fellows. Acad Med. 2004;79:698–702.

    PubMed  Article  Google Scholar 

  4. Epstein RM, Dannefer EF, Nofziger AC, Hansen JT, Schultz SH, Jospe N, et al. Comprehensive assessment of professional competence: the Rochester experiment. Teach Learn Med. 2004;16:186–96.

    PubMed  Article  Google Scholar 

  5. Beullens J, Rethans JJ, Goedhuys J, Buntinx F. The use of standardized patients in research in general practice. Fam Pract. 1997;14:58–62.

    PubMed  Article  CAS  Google Scholar 

  6. Tamblyn RM. The use of standardized patients in the assessment of medical practice. Can Med Assoc J. 1998;158:205–7.

    CAS  Google Scholar 

  7. Peabody JW, Luck J, Glassman P, Dresselhaus TR, Lee M. Comparison of vignettes, standardized patients, and chart abstraction. A prospective validation study of 3 methods of measuring quality. JAMA. 2000;283:1715–22.

    PubMed  Article  CAS  Google Scholar 

  8. Beaulieu MD, Rivard M, Hudon E, Saucier D, Remondin M, Favreau R. Using standardized patients to measure professional performance of physicians. Int JQual Health Care. 2003;15:251–9.

    Article  Google Scholar 

  9. Dresselhaus TR, Peabody JW, Lee M, Wang MM, Luck J. Measuring compliance with preventive care guidelines: standardized patients, clinical vignettes, and the medical record. J Gen Int Med. 2000;15:782–8.

    Article  CAS  Google Scholar 

  10. Carney PA, Dietrich AJ, Freeman DH Jr, Mott LA. The periodic health examination provided to asymptomatic older women: An assessment using standardized patients. Ann Int Med. 1993;119:129–35.

    PubMed  CAS  Google Scholar 

  11. Carney PA, Ward DH. Using unannounced standardized patients to assess the HIV preventive practices of family nurse practitioners and family physicians. Nurse Pract. 23;56–8, 63, 67–8 passim; 1998.

  12. Hutchinson B, Woodward CA, Norman GR, Abelson J, Brown JA. Provision of preventive care to unannounced standardized patients. Can Med Assoc J. 1998;158:185–93.

    Google Scholar 

  13. Gorter S, Rethans JJ, van der Heijde D, Scherpbier A, Houben H, van der Vleuten C, et al. Reproducibility of clinical performance assessment in practice using incognito standardized patients. Med Educ. 2002;36:827–32.

    PubMed  Article  Google Scholar 

  14. Franz CE, Epstein R, Miller KN, Brown A, Song J, Feldman M, et al. Caught in the act? Prevalence, predictors, and consequences of physician detection of unannounced standardized patients. Health Serv Res. 2006;41:2290–302.

    PubMed  Article  Google Scholar 

  15. Srinivasan M, Franks P, Meredith LS, Fiscella K, Epstein RM, Kravitz RL. Connoisseurs of care? Unannounced standardized patients’ ratings of physicians. Med Care. 2006;44:1092–8.

    PubMed  Article  Google Scholar 

  16. Standards of medical care in diabetes-07. Diabetes Care. 2007;30(Suppl 1):S4–41.

    Google Scholar 

  17. Saydah SH, Fradkin J, Cowie CC. Poor control of risk factors for vascular disease among adults with previously diagnosed diabetes. JAMA. 2004;291:335–42.

    PubMed  Article  CAS  Google Scholar 

  18. Saaddine JB, Engelgau MM, Beckles GL, Gregg EW, Thompson TJ, Narayan KM. A diabetes report card for the United States: quality of care in the 1990s. Ann Intern Med. 2002;136:565–74.

    PubMed  Google Scholar 

  19. Peters AL, Legorreta AP, Ossorio RC, Davidson MB. Quality of outpatient care provided to diabetic patients. A health maintenance organization experience. Diabetes Care. 1996;19:601–6.

    PubMed  Article  CAS  Google Scholar 

  20. Suwatee P, Lynch JC, Pendergrass ML. Quality of care for diabetic patients in a large urban public hospital. Diabetes Care. 2003;26:563–8.

    Article  Google Scholar 

  21. Gilbert EH, Lowenstein SR, Koziol-Mclain J, Barta DC, Steiner J. Chart reviews in emergency medical research: where are the methods. Ann Emerg Med. 1996;27:305–8.

    PubMed  Article  CAS  Google Scholar 

  22. Wu L, Ashton CM. Chart review: a need for reappraisal. Eval Health Prof. 1997;20:146–63.

    PubMed  Article  CAS  Google Scholar 

  23. Luck J, Peabody JW, Dresselhaus TR, Lee M, Glassman P. How well does chart abstraction measure quality? A prospective comparison of standardized patients with the medical record. Am J Med. 2000;108:642–9.

    PubMed  Article  CAS  Google Scholar 

  24. Garnick DW, Fowles J, Lawthers AG, Weiner JP, Parente ST, Palmer RH. Focus on quality: profiling physicians’ practice patterns. J Ambul Care Manage. 1994;17:44–75.

    PubMed  CAS  Google Scholar 

  25. Tan KBH. Assessing Doctors’ Compliance with Guidelines on Diabetes Management. Int J Health Care Qual Assur. 2006;19:267–86.

    Article  Google Scholar 

  26. Sequist TD, Gandhi TK, Karson AS, Fiskio J, Bugbee D, et al. A randomized trial of electronic clinical reminders to improve quality of care for diabetes and coronary artery disease. J Am Med Inform Assoc. 2005;12:431–7.

    PubMed  Article  Google Scholar 

  27. Kirkman MS, Williams SR, Caffrey HH, Marrero DG. Impact of a program to improve adherence to diabetes guidelines by primary care physicians. Diabetes Care. 2002;25:1946–51.

    PubMed  Article  Google Scholar 

  28. Gulliford MC, Ashworth M, Robtham D, Mohiddin A. Achievement of metabolic targets for diabetes by English primary care practices under a new system of incentives. Diabet Med. 2007;24:505–11.

    PubMed  Article  CAS  Google Scholar 

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Acknowledgements

This project was funded in part through an educational research grant from the Quality Care Research Fund, Aetna U.S. Healthcare, and has been presented in abstract form at the Southern Regional Meeting of the Southern Society of Clinical Investigation, February 2002, and the AAMC Annual Meeting, San Francisco, CA, November 2002.

Conflict of Interest

None disclosed.

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Authors and Affiliations

  1. Tulane University Health Sciences Center, New Orleans, LA, USA

    N. Kevin Krane MD, Delia Anderson MS, Cathy J. Lazarus MD, Michael Termini MD, Bruce Bowdish PhD, Sheila Chauvin PhD & Vivian Fonseca MD

  2. Department of Medicine, Tulane University School of Medicine, 1430 Tulane Avenue, SL-95, New Orleans, LA, 70112-2699, USA

    N. Kevin Krane MD & Vivian Fonseca MD

Authors
  1. N. Kevin Krane MD
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  2. Delia Anderson MS
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  3. Cathy J. Lazarus MD
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  4. Michael Termini MD
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Correspondence to N. Kevin Krane MD.

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Krane, N.K., Anderson, D., Lazarus, C.J. et al. Physician Practice Behavior and Practice Guidelines: Using Unannounced Standardized Patients to Gather Data. J GEN INTERN MED 24, 53–56 (2009). https://doi.org/10.1007/s11606-008-0826-3

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  • DOI: https://doi.org/10.1007/s11606-008-0826-3

KEY WORDS

  • standardized patients
  • practice guidelines